5 why analysis with breakdown eg

Our Goal : Zero Defect, Zero Breakdown

Our Goal : Zero Defect, Zero Breakdown

Root Cause Analysis

Content

1. Objective

2. Basic Approach

3. Example

Our Goal : Zero Defect, Zero Breakdown

Objective

• Zero Defect

• Zero Breakdown

• Zero Safety Risk

• Low Maintenance Cost

• Higher Productivity

• Effective Operability

• Low Variability

Our Goal : Zero Defect, Zero Breakdown

Approach

• A disciplined method using a logic tree

• A logic tree is required to represent

Cause and effect relationships

that lead to surfacing the undesirable event

Our Goal : Zero Defect, Zero Breakdown

Approach

What is the Logic Tree

What is the cause and effect relationship ??This will be explained in the coming slides during the presentation

A graphical way of representing Cause and effect relationship.

Our Goal : Zero Defect, Zero Breakdown

How to do the 5 - Why Analysis

Our Goal : Zero Defect, Zero Breakdown

How to do 5 - Y Analysis

Step 1:Step 1:• Identify the undesirable event and its

Important

• Facts are supported by some essence of

science, direct observation & documentation

with supporting factsassociated reason

Our Goal : Zero Defect, Zero Breakdown

Step 2:Step 2:

• Once identified the effect and reason.

• Find the reason as “ HOW” did it fail

Important

• Do not work out for assumptions.

• Only physical evidence, technical reason is

valid.

How to do 5 - Y Analysis

Our Goal : Zero Defect, Zero Breakdown

Note:Note:

•The facts cannot be hearsay or

assumptions !!

Evidence of MODE/ Reason

How to do 5 - Y Analysis

BUT Supported by

Our Goal : Zero Defect, Zero Breakdown

The End !!

Our Goal : Zero Defect, Zero Breakdown

If the above steps are so simple then…………...

Our Goal : Zero Defect, Zero Breakdown

If two guys are made to do the RCA of the same problem

WHY isPossibility of difference in the conclusions drawn by them

Our Goal : Zero Defect, Zero Breakdown

Where is the Gap ???

Our Goal : Zero Defect, Zero Breakdown

We need to explore the discipline necessary to provide consistency to our RCA Application

Thus Improving the credibility and

communication of the results

What is required to be done

Our Goal : Zero Defect, Zero Breakdown

How to improve credibility and communication of the results.

How to do it

Better Understanding

Use disciplinedthought process

to seek trueroot cause

We are not checkingthe thought process

that drew the conclusions

Impart training to bring a common understanding

into the process

Our Goal : Zero Defect, Zero Breakdown

Now let us do a 5 - Why analysis with an example

……….Hmmm undesirable Event

Our Goal : Zero Defect, Zero Breakdown

Sir, Pumpbearingfailed

Ask the fitter toChange it…. Pumpshould start now..

Our Goal : Zero Defect, Zero Breakdown

What was the problem

What did we do

What was to be done

What was the reason

Come on.. lets do the Root Cause Analysis

Our Goal : Zero Defect, Zero Breakdown

From Where do we start

Why did Pump Failed ??

Why did Bearing failed ??

OR

Getting Started…………..

Our Goal : Zero Defect, Zero Breakdown

Root Cause AnalysisRoot Cause Analysis1

First WhyFirst Why

Our Goal : Zero Defect, Zero Breakdown

When the event occurred, why was it brought to our attention

•Because the bearing failed

•Because the Pump FailedAnswer :

It was brought to our attention because

Therefore the last effect that caused us concern was the pump failure

One reason (MODE) that pump failed was

OR

due to bearing failure

the failed bearing caused a pump to stop pumping Oil.

From where should I begin…...

Our Goal : Zero Defect, Zero Breakdown

Evidence :

Answer

Thus we have

Event :Pump FailureMode : Bearing Failure (Supported by evidence)

Physically observed.

How can you say that it

failed because of bearing?

Objective Evidence

Our Goal : Zero Defect, Zero Breakdown

Effect

Reason

Pump Failure

Bearing failure

Logic Tree

WHY

Our Goal : Zero Defect, Zero Breakdown

Thus is any step of evaluation (first Why to 5 why)One is the effect and

Each reason is to be evaluated with

evidence to justify the reason

Other is reason(s)

Thus the relationship between the cause and effect lies with the

Evidence

Cause and Effect Relationship

Our Goal : Zero Defect, Zero Breakdown

Example :Bearing Failure caused a

pump to stop working.

• Last Effect is :

• Mode (reason)

:• Evidence of

Mode ( Reason)

- Pump Failure

- Bearing failed

- Physical evidence

Relationship

Cause and Effect Relationship

Our Goal : Zero Defect, Zero Breakdown

What is Evidence

It can be any clarification based on

• Technical Reasoning

• Physical Evidence• Supporting data viz..Asset care, Condition Appraisal, Log book etc

BUT CANNOT BE BASED ON ASSUMPTIONS

Our Goal : Zero Defect, Zero Breakdown

Learning from this

For any undesirable event (Effect) …..there is one or more reason(s) And we need to hunt them down

For any reason (mode) / Cause we find…..we need to justify it

With a objective evidence

Cause / Reason

EffectObjectiveEvidence

Cause Effect Relationship

Our Goal : Zero Defect, Zero Breakdown

MODULE MODULE 2

Second WhySecond Why

Our Goal : Zero Defect, Zero Breakdown

Often it happens we tend to conclude fasterwith our preset mind

Jumping to Conclusion

Our Goal : Zero Defect, Zero Breakdown

Why did the bearing Failed ??

Dear brother itfailed due to someforeign particle Entering in it

We perceive a problem to exist and we go right to what the most obvious cause is to US

Mind Set

No doubt we cannot deny this reason….but need to have an evidence

This is the FINISHED PRODUCT APPROACH

Our Goal : Zero Defect, Zero Breakdown

Finished Product Approach :

We perceive a problem to exist and we go the right to what the most obvious cause is TO US !!We do not validate any of our assumptions, we just assume a cause and spend money to implement a fix and hope it works

Experience shows this approach to beineffective and very expensive.

Our Goal : Zero Defect, Zero Breakdown

Now Let us find the Second why but in a different way ??

Our Goal : Zero Defect, Zero Breakdown

Why did the bearing Fail ??

Hmm…Erosion,Corrosion,Fatigue,Overload

For this we need to think we an open mind.At times we need to consult others

Mind Set

This is the DISCIPLINED THOUGHT PROCESS TO SEEK RESULT

WhyHow candid

Our Goal : Zero Defect, Zero Breakdown

Continuing our search backwards for the cause and effect relationships

We would then ask

How can a bearing fail ??

Our Hypothesis may be

Erosion, Corrosion, Fatigue, Overload

How can we prove which are true ( Evidence)

Note : We asked How can a bearing fail and not Why did a bearing fail

How can it fail -----this is brainstorming

Out of the various reasons you brainstormed, you look for the evidence.And then conclude…..bearing failed….why….due to…fatigue…evidence...

Our Goal : Zero Defect, Zero Breakdown

Search for Evidence

Hypothesis Verification Techniques

Erosion,Corrosion,Fatigue, Overload Metallurgical Analysis

High Vibration Vibration monitoring inst.

Misalignment Laser Alignment technology

While carrying out the investigation, metallurgical and physical test proved that it failed due to fatigue.

Our Goal : Zero Defect, Zero Breakdown

ErosionErosion

EffectReason

OverloadOverloadCorrosionCorrosion FatigueFatigue

Logic Tree

Pump Failure

Bearing failure

Why

How Can ??

Why

Our Goal : Zero Defect, Zero Breakdown

MODULE MODULE 3

Third WhyThird Why

Our Goal : Zero Defect, Zero Breakdown

You can now see that as we develop new sets of hypotheses, we are proving what we say at each level of the process.

This is demonstrating quality of process.When we continue this reiterative process, we are validating our conclusions each step of the way.

This way, when we draw our conclusions about root causes, they will be right because we have supported them based on fact and not mere assumption.

Our Goal : Zero Defect, Zero Breakdown

Logic Tree

ErosionErosion

Effect

Pump Failure

Bearing failure

OverloadOverloadCorrosionCorrosion FatigueFatigue

Reason High Vibration

Evidence / Notes for clarification: Asset Care Check list states vibration was observed from past 5 days (PAST DATA)

Why

How Can ??

How Can ??

Our Goal : Zero Defect, Zero Breakdown

MODULE MODULE 4

Fourth WhyFourth Why

Our Goal : Zero Defect, Zero Breakdown

When most people conduct their version of Root Cause Analysis (RCA),Where do they usually stop?How do they know they are done? How do they know that the problem will not reoccur?

These questions represent reality when we are the ones in the field working on a pressing problem with management on our backs.

If we consider ourselves manufacturing detectives, are we content with the stopping at the “HOWS” or the “WHYS”

Our Goal : Zero Defect, Zero Breakdown

Erosion

Pump Failure

Bearing failure

OverloadCorrosion Fatigue

Reason

Effect High Vibration

Logic Tree

ResonanceImbalance Misalignment

Why

How Can ??

How Can ??

How Can ??

Our Goal : Zero Defect, Zero Breakdown

MODULE MODULE 5

Fifth WhyFifth Why

Our Goal : Zero Defect, Zero Breakdown

Reason

Logic Tree

Effect

Pump Failure

Bearing failure

Why

Erosion OverloadCorrosion Fatigue

How Can ??

High Vibration

How Can ??

ResonanceImbalance Misalignment

How Can ??

ImproperToolsNo Procedures

Inadequate training

Why

Reason

Effect 1st Why2nd Why

Effect

Rot cause analysis

Root Cause Analysis

Reason

Rot cause analysis

3 rd Why

Reason

4 th Why

Root Cause Analysis

5 th Why

Effect

Reason

Root Cause Analysis

Effect Rot cause an

Our Goal : Zero Defect, Zero Breakdown

Now tell me when we typically

conduct analyses, are we more like a

engineer or the prosecutor and the detective looking to

win his case?

What is the difference between the those roles?

Our Goal : Zero Defect, Zero Breakdown

How to do it

Engr’s role is to determine with science HOW event

occurred ?Then what is the

role of prosecutor and detectives??

Yes !! they in essence will map out HOW

the crime occurred and be able to prove that it happened just

that way.

This means that a certain sequence of cause and effect

relationships linked up and resulted in the undesirable event.

Their role is to prove that each hypothesis did or did not occur.

Role of prosecutor

& detectives is typically to determine

WHY.

Our Goal : Zero Defect, Zero Breakdown

We should use our Technology to prove or disprove our

hypotheses and then explore Why people make decisions that result in the undesirable outcomes or

failure

Summary:

First WE must provide the HOW pieces of puzzle and then determine why decisions that lead to the undesirable outcome

Our Goal : Zero Defect, Zero Breakdown

Let us look at the example we studied……….

Our Goal : Zero Defect, Zero Breakdown

Logic Tree

Reason

Pump Failure

Bearing failure

Why

Erosion OverloadCorrosion Fatigue

How Can ??

High Vibration

How Can ??

ResonanceImbalance Misalignment

How Can ??

ImproperTools

No Procedures Inadequate training

Why

Effect

Reason

Physical

Human

Latent Latent Latent

Our Goal : Zero Defect, Zero Breakdown

The undesirable event is : pump failure

Hypothesis Verification Techniques

Erosion,Corrosion,Fatigue, Overload Metallurgical Analysis

High Vibration Vibration monitoring inst.

Misalignment Laser Alignment technology

We must understand the cause and effect relationships that lead to the event

These questions answer how??But what about why

This will require evidence to prove our hypothesis

Our Goal : Zero Defect, Zero Breakdown

In this case someone misaligned a pump and that decision resulted in a sequence of cause & effect relationship that caused the pump to fail prematurely.

Our Goal : Zero Defect, Zero Breakdown

Now the question is WHY would a person choose to align in that fashion !!

Our Goal : Zero Defect, Zero Breakdown

If we were to go deeper & understand

the thought process or the rational for such a decision (Latent Root),

we would uncover the REALROOT CAUSE.

I got it!!It means that either he was not trainedNo SOP available, tools worn out or inadequate

YES Exactly !!

Our Goal : Zero Defect, Zero Breakdown

If we do not explore the WHY,then HOW is likely to reoccur

Our Goal : Zero Defect, Zero Breakdown

If you now reflect on your current RCA efforts, do you stop at the how or at the WHY

Our Goal : Zero Defect, Zero Breakdown

Think about it……………….

Our Goal : Zero Defect, Zero Breakdown

Thank You !!